Monday, April 09, 2007

Unusual Weekend

It's been a bit of an unusual weekend for that I've actually done three jobs that were actually worth going to as they really did need an ambulance.

The first one wasn't actually a category A call, it was an Amber 2, but I could see why they'd sent me. It was given as a male who'd amputated four fingers. I arrived to find the patient holding a dirty rag over his hand, and walking up and down trying to find the shattered ends of his fingers. His friend was talking animatedly in Polish to a friend on the phone, and thrust the phone towards me as I walked through the door.
"Can you talk to my friend please?"
" I need to assess your friend first," I told him. He resumed his conversation.
"What exactly happened?" No response. The patient continued looking for his finger ends, and the friend continued his telephone conversation.
I spotted a makeshift tourniquet tied round the wrist of the injured hand. I managed to stop the patient (who spoke very little English) looking for his finger ends long enough for me to remove the tourniquet, and the dirty rag from the hand. Amputations actually bleed very little, because of the body's natural reaction to this type of injury is to narrow off the blood vessels to limit blood loss - indeed there were only a few small drops of blood on the floor, and little on the rag, so the tourniquet wasn't really needed. I examined the damage, and found that he'd "only" cut the ends off his index and ring fingers, but they were rather mangled. I dressed his hand with a large dressing to cover all of his fingers. It turned out that he'd been cutting a piece of wood lengthways with a jig-saw when he'd failed to stop at his hand, and lopped his finger ends off. Quite how he missed his middle finger, I do not know. I joined the search for viable pieces of his fingers that a surgeon could re-attach, but they'd all been sliced quite thinly. The one sizeable chunk appeared to be from his index finger, but that was rather mangled and the patient had apparently stood on it a few times in his search, so it was unusable. The crew arrived, I handed over, and they took him off to hospital.

The second was an RTC - given as Car Vs Pedestrian. It turned out to be a woman who'd been crossing the road between stationary traffic, but hadn't realised that the traffic in the opposite direction was still moving freely, and she'd simply walked out in front of a car, which had side-swiped her at about 35mph. fortunately, the two dogs she was walking at the time escaped without being hit and whilst clearly upset that their owner was hurt, were unhurt.
The police had just arrived when I got there. There were only two officers, one of which was knelt next to my patient who was writhing around in pain on the road. I went across, and began assessing the patient. She was complaining of head, neck, back pain, and she had pain in her right foot. With that, I took hold of her head to stabilise the neck, and then had to try and persuade her to keep still - which wasn't easy because she wasn't very compliant, which is a sign of head injury.
The two officers were now involved with keeping the nosey bystanders at bay and directing traffic arround us to keep us safe, so I couldn't ask them to get more equipment out of the car for me. Fortunately the crew arrived about a minute later, and seeing me kneeling holding the head, straight away got the neck collars and other equipment, as a second FRU arrived to help. I maintained control of the head as the crew and 2nd FRU applied the collar, looked for other injuries, and got her onto a metal stretcher and strapped her down to stop her moving about.
One of the crew cut the shoe and sock off the right foot, and found that it had been "de-gloved" which means the skin had been torn off and the bones of the foot were visible.
We got her onto the ambulance, and the crew blued her in to the hospital which was about three minutes down the road.
The police had requested that the RSPCA attend to check the dogs were ok, which they were, and then they were taken home where there was someone to look after them.

When I first got the third job, I thought it had been sent to the wrong car by mistake. It was given as an 88 year old female, not responding, difficulty in breathing and blue round the lips, and it was miles away. I was just about to ask control on the radio if they'd meant to send it to me when the phone rang.
"Sorry, I know this job's a bit of a trek for you, but we've nothing else to send. Everything's busy on calls, and the FRU for that area is on a resus. Can you go and have a look for us, and we'll make sure we get the first available ambulance to you." I'd heard that before, when I'd covered a shift for someone.
So off I went. It was to a nursing home. I prepared myself for staff that knew nothing about the patient and a long wait at the door.
The wait wasn't as long as I've known before, but someone came, saw me through the glass of the door, and instead of letting me in, walked off in a hurry shouting "There's an ambulance guy at the door!" Someone eventually let me in, and after asking a few people who we'd been called for, led me to the room of one of the residents, ambling down the corridor as if there wasn't anything particularly to worry about.
I entered the room, to find a male nurse doing CPR on the patient. The patient was on the bed, and the patient was bouncing up and down on the mattress with each chest compression.
The nurse stopped as soon as he saw me. "Don't stop!" I told him, and worked on lowering the sides of the bed. "Right, let's get her on the floor." This would make the chest compressions much more effective. We lifted her from the bed, the nurse at the head end, and as we were loweering her onto the floor, he dropped her, her head hitting the floor rather hard.
"Sorry, sorry," he kept saying. I pushed him out of the way, and instructed him to continue with chest compressions. I attached the defibrillator and switched it on, which showed asystole - flat line. I hoped there was a paramedic on the crew so that we could terminate resuscitation if there was no response after doing CPR for a certain amount of time. I ventilated the patient, and whilst doing so, rang control to tell them I needed an ambulance urgently as the patient was now in cardiac arrest. They told me the crew had just pulled up outside. They were a double technician crew. One of them took over chest compressions, while the other went to fetch the trolley bed. A second crew arrived to help....also a double technician crew. We got her onto the trolley and into the back of the ambulance. We paused for the defibrillator to analyse the electrical activity in the heart. It showed a normal rhythm, but there was no pulse - PEA.
We continued CPR for a further two minutes, while we were being driven to the hospital. Another pause to analyse. During this pause, I looked at the patient's chest. I could see movement as the heart pumped beneath. "We've got an output," I said, feeling for a pulse. I still couldn't find one. I looked at the chest again. It was still there. By this time, we were just pulling into the hospital, so didn't have time to get a blood pressure. I handed over to the hospital staff, and a nurse said, "Oh she's apparently got an output."
"I can't feel anything," said a doctor feeling for a pulse at the neck.
"Shall I start CPR?" asked another.
I could still see the movement in the chest, and I pointed it out to one of the doctors. They remained unconvinced. Then a nurse feeling for a pulse at the femoral artery at the very top of the leg said she could feel a pulse.
We left the staff to it, and went out to the ambulance to do the paperwork. I went back in to pick up some equipment, and saw that everything had been disconnected. The patient had died.

Sometimes we can only try and hope. The simple fact is that most people who suffer a cardiac arrest don't recover. Having said that, since the new resuscitation guidelines came in last year, more and more success stories are being reported. I was convinced that this lady would stay in asystole all the way to hospital, and that the resuscitation effort would be stopped almost as soon as we'd got through the door. The fact that we got an output back shows how important it is to learn CPR and be prepared to provide it if and when it is needed.
When I arrived, the nurse was providing good compression-only CPR, albeit on the bed, which is what probably lead to us being able to get the heart going again, but it seems it was just this lady's time to go.

Both St John Ambulance and the British Red Cross provide basic first aid courses, including CPR training. You can find the number for your local branch via the website or in the phone book. In London, you can also contact the Community Resuscitation Team for details of courses. The contact details can be found on the London Ambulance Service website.


Anonymous drunkenspaniel said...

Blimey! 3 decent jobs in one shift - that is unusual!

First time I've seem your blog. I've added you to my list...

8:36 pm  

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